Sex, not unsafe medical practices, is the primary mode of HIV transmission in sub-Saharan Africa, according to a study published in the Feb. 7 issue of the Lancet, Reuters reports (Reuters, 2/5). George Schmid of the World Health Organization and colleagues from UNAIDS; the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium; the Joint Clinical Research Centre in Kampala, Uganda; Imperial College in London; CDC; the London School of Hygiene and Tropical Medicine; the Harvard School of Public Health and the Yale School of Medicine reviewed and reinterpreted studies conducted by anthropologist David Gisselquist, who has claimed that unsafe medical injections are a primary source of HIV transmission in sub-Saharan Africa (Schmid et al., Lancet, 2/7). Gisselquist and a team of seven researchers in March 2003 published three studies in the International Journal of STD & AIDS claiming that unsafe medical practices could account for between 20% and 40% of HIV infections in the Southern African region. The group in May 2003 published a similar study in the British Journal of Obstetrics and Gynaecology (Kaiser Daily HIV/AIDS Report, 10/2/03). Schmid and colleagues argue that about 39% of the average 3.4 injections given per person per year in low-income and middle-income countries are given with unsterile equipment, which is "considerably less" than the 50% of injections cited by Gisselquist and colleagues. In addition, a majority of injections in sub-Saharan Africa are given intramuscularly, and blood contamination through such injections is infrequent, the researchers say. The likelihood of contamination is further reduced by "commonly used" practices such as flushing the syringe with water, according to the researchers (Lancet, 2/7). The researchers also noted that HIV incidence is lower among children, who are in general not sexually active, suggesting a link between sexual activity and HIV infection, the Associated Press reports (Koppel, Associated Press, 2/5).

Conclusions
"Unless there are huge disparities in injection practices between children and adults, only sexual transmission can explain the seroprevalence differences by age," the researchers conclude, adding that their reinterpretation of the studies of Gisselquist and colleagues provide "no compelling evidence that unsafe injections are a dominant mode of HIV-1 transmission in sub-Saharan Africa." Although unsafe injections are an "unacceptable practice" and efforts to eliminate them should be increased, sexual transmission continues to be the primary mode of HIV transmission in sub-Saharan Africa, the researchers conclude (Lancet, 2/7). Schmid endorsed WHO's estimate that 2.5% of HIV/AIDS cases in sub-Saharan Africa are linked to unsafe injections, according to Reuters. "Ideally, we would like to see further studies done to corroborate our conclusions and investigate more precisely the role of unsafe injections," he said. By reasserting that up to 90% of adult HIV cases in the region are linked to sexual contact, the researchers "vindicated" existing prevention programs that focus on safe sex education and condom use, according to Reuters. "A lot of prevention programs that have been going on in Africa should be continued," Peter Ghys of UNAIDS, who took part in the study, said, adding, "With there being much more funding available, there is an opportunity to expand those programs" (Reuters, 2/5).

This article was provided by Henry J. Kaiser Family Foundation. It is a part of the publication Kaiser Daily HIV/AIDS Report.
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